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Esophagectomy—It’s Not Just About Mortality Anymore: Standardized Perioperative Clinical Pathways Improve Outcomes in Patients with Esophageal Cancer

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Esophageal resection (ER) remains the standard therapy for early esophageal cancer; however, because of concerns regarding high levels of morbidity and mortality reported in analyses of national databases, many patients are relegated to less effective endoscopic or chemotherapeutic approaches.

Methods

All patients undergoing esophagectomy by a single surgeon for cancer or high-grade dysplasia between 05/91–05/06 were prospectively entered into an IRB-approved database. All aspects of work-up and treatment were guided by an evolving standardized perioperative clinical pathway.

Results

Three hundred forty consecutive patients, mean age of 64 (33–90), underwent ER for Barrett’s esophagus (17) or invasive cancer stages I-87, II-133, III-94, IV-9. One hundred thirty-nine (41%) had neoadjuvant therapy. Sixty-three percent were American Society of Anesthesiologists class III or IV, and five different operative approaches were used. Patient were managed intraoperatively with a “fluid restriction” protocol. Mean intraoperative blood loss was 230 cc. 99.5% of patients were extubated immediately, and mean ICU and hospital stays were 2.25 (1–30) and 11.5 (6–49) days, respectively. Postoperative analgesia was managed with patient-controlled epidural analgesia in 98.5%, and 86% were mobilized on day 1 after surgery. Complications occurred in 153 patients (45%), most commonly atrial dysrhythmia (13%), and postoperative delirium (11%). Anastomotic leaks occurred in 13 patients (3.8%). Mortality occurred in one patient (0.3%). No significant differences were seen in length of stay, operative time, blood loss, or complications in patients receiving neoadjuvant therapy. For stages I, II, and III, patients between 1998–2004 Kaplan–Meier 5-year cumulative survival was 92.4, 57.1, and 34.5%, respectively.

Conclusions

Surgical treatment of esophageal cancer can be done with moderate morbidity and very low mortality, and the expectation of improved levels of survival, especially in early-stage patients. Standardized perioperative clinical pathways can provide the infrastructure for the treatment of these patients and should include increased efforts to minimize blood loss and transfusions, improve postoperative pain control and extubation rates, and facilitate early mobilization and discharge. ER, as sole therapy or in combination with radiation/chemotherapy, should remain the standard of care in patients with early and locoregional esophageal cancer.

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Authors and Affiliations

  1. Thoracic Oncology Program and Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA

    Donald E. Low, Sonia Kunz, Drew Schembre, Henry Otero, Tom Malpass, Alex Hsi, Guobin Song, Richard Hinke & Richard A. Kozarek

  2. Section of General Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave. C6-SUR, Seattle, WA, 98111, USA

    Donald E. Low

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DISCUSSION

Jeffrey H. Peters, M.D. (Rochester, NY): Following on Dr Traverso’s Presidential address, as a high volume report from a single surgeon, it is of course not the average of the average. Nevertheless, Bill, there is still much to be gleaned from studies like this. Dr Low did a good job of outlining why the data are important, not the least of which is because controlled studies are so rare in this area of major resections; as such we are always comparing ourselves to yesterday and not to today. So it is important that we have modern outcome data. It also is quite true, as the title points out, it is not all about mortality anymore, more patients are surviving longer, and being cured.

I will ask you one simple and one conceptual question, Don. The first is, do you think we can do without the ICU post-esophagectomy. This thought has crossed my mind from time to time, as we may be getting into an era where ICU stays are no longer necessary in most, if not all, of these patients.

More conceptually, are the boundaries of the morbidity and mortality of the various treatment options coming close enough together so that, as Bill so nicely pointed out in his presidential address, we should stop focusing on the extent of the treatment, and start focusing more on the environment that the treatment takes place in? Is this true given our endoscopic, minimally invasive and/or open surgical treatment options? Great paper, Don. I enjoyed it you very much and thank you for the opportunity to discuss the data.

Donald E. Low, M.D. (Seattle, WA): Dr. Peters, thank you very much. With respect to the ICU, I think that part of the answer can be taken from the fact that in 1992 our goal was to discharge patients from the ICU in 48 to 72 h. Now our goal within the pathway is to discharge patients from the ICU in 12 to 18 h. Can it be eliminated? Yes, I think it can. However, I believe that we have to make sure that we have developed specialized units within our hospital to make sure that the nursing care and the other ancillary support infrastructure that we have to manage these patients immediately after surgery is in place on the ward. Selected patients do not require the same level of monitoring but do require experienced personnel to be involved in their immediate post-operative care.

The second question I think is extremely intuitive and probably the most important question that we should address. Does it matter how we are doing these operations? Although we should be able to diversify our approach, the basic answer is probably no. The corollary of that is, we must know our individual results. We must know what our outcomes are, including mortality, morbidity, survivorship, and quality of life. This will be particularly important as minimally invasive surgical approaches continue to evolve.

John G. Hunter, M.D. (Portland, OR): Don, again, a very nice paper. What you have shown is that as mortality has fallen out as your largest problem, your number one complication now is atrial dysrhythmia, and in order to get better we take our number one complication and we go to work on it. You and I both believe, I know, that this is a complication unto itself and not a harbinger of some other complication as has been reported by the Hong Kong group. What are you doing about that, any pretreatment, post-treatment? How are you working on this problem?

Dr. Low: Thank you for that lead-in, because I think your starting comment was right: If we are going to continue to improve our results we must take the problems that are afflicting us most and analyze them separately. Currently in front of our IRB is a proposal for a randomized clinical trial in which we are going to start utilizing antiarrhythmic medications prior to esophageal resections. We are specifically proposing a trial utilizing amiodarone in an attempt to decrease the incidence of post-operative atrial dysrhythmias. We have not observed that atrial fibrillation is a problem which indicates that something more ominous is going on. It is, however, a major issue in a certain component of our patient population which delays discharge and increases costs.

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Low, D.E., Kunz, S., Schembre, D. et al. Esophagectomy—It’s Not Just About Mortality Anymore: Standardized Perioperative Clinical Pathways Improve Outcomes in Patients with Esophageal Cancer. J Gastrointest Surg 11, 1395–1402 (2007). https://doi.org/10.1007/s11605-007-0265-1

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